Hindawi Publishing Corporation Case Reports in Volume 2014, Article ID 868390, 9 pages http://dx.doi.org/10.1155/2014/868390

Case Report Class III Surgical-Orthodontic Treatment

Bruna Alves Furquim, Karina Maria Salvatore de Freitas, Guilherme Janson, Luis Fernando Simoneti, Marcos Roberto de Freitas, and Daniel Salvatore de Freitas BauruDentalSchool,UniversityofSao˜ Paulo, Al. Octavio´ Pinheiro Brisolla, 9-75, 17012-901 Bauru, SP, Brazil

Correspondence should be addressed to Bruna Alves Furquim; [email protected]

Received 23 April 2014; Revised 23 September 2014; Accepted 19 October 2014; Published 6 November 2014

Academic Editor: Husamettin¨ Oktay

Copyright © 2014 Bruna Alves Furquim et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The aim of the present case report is to describe the orthodontic-surgical treatment of a 17-year-and-9-month-old female patient with a Class III malocclusion, poor facial esthetics, and mandibular and chin protrusion. She had significant anteroposterior and transverse discrepancies, a concave profile, and strained lip closure. Intraorally, she had a negative overjet of 5 mm and an of 5 mm. The treatment objectives were to correct the malocclusion, and facial esthetic and also return the correct function. The surgical procedures included a Le Fort I osteotomy for expansion, advancement, impaction, and rotation of the maxilla to correct the occlusal plane inclination. There was 2 mm of impaction of the anterior portion of the maxilla and 5 mm of extrusion in the posterior region. A bilateral sagittal split osteotomy was performed in order to allow counterclockwise rotation of the mandible and anterior projection of the chin, accompanying the maxillary occlusal plane. Rigid internal fixation was used without any intermaxillary fixation. It was concluded that these procedures were very effective in producing a pleasing facial esthetic result, showing stability 7 years posttreatment.

1. Introduction are three main treatment options for skeletal Class III maloc- clusion: growth modification, dentoalveolar compensation, Occlusal discrepancies and moderate and severe dental and and orthognathic . Growth modification should be facial deformities in adults usually require treatment com- initiated before the pubertal growth spurt; afterwards, only bined with and orthognathic surgery to achieve two options are possible [6]. Thus, treatment of skeletal Class optimal, stable, functional, and esthetic results. The basic III malocclusion in an adult requires orthognathic surgery objectives of orthodontics and orthognathic surgery are to combined with conventional orthodontic treatment aiming meet patient’ complaints, establish optimal functional out- to improve self-esteem and achieve normal and comes, and promote good esthetic results. To achieve this, the improvement of facial esthetics [7, 8]. Proffit et al. [9]found orthodontistandthesurgeonmustbeabletocorrectly that psychological rather than morphologic characteristics diagnose dental and skeletal deformities and establish an probably were the major reason on whether or not an indi- appropriate treatment plan for that patient [1]. Class III vidual decided to accept surgery. Bell et al. [10]alsopointed malocclusion is a difficult anomaly to understand. Studies outthatthedecisionofsurgerywasmainlyrelatedtopatients’ conducted to identify the etiologic features of Class III maloc- self-perception. clusion showed that the deformity is not restricted to the jaws Surgical treatment of Class III malocclusion includes, in butinvolvesthetotalcraniofacialcomplex[2, 3]. Most most cases, mandibular retrusion, maxillary protrusion, or a subjects with Class III have combinations of combination of both [6]. Mandibular clockwise rotation can skeletal and dentoalveolar components [4]. The factors con- also provide the same result as mandibular retrusion, when tributing to the anomaly are complex. increase of lower anterior face height is allowed. Therefore, In skeletal Class III cases, it may be difficult to achieve an the objective of this paper is to present a case of a skele- excellent occlusal outcome only with orthodontic treatment tal Class III malocclusion orthodontic surgically treated. and to maintain a stable posttreatment occlusion [5]. There Although the problem appeared to be a protruded mandible, 2 Case Reports in Dentistry

Figure 1: Pretreatment extraoral and intraoral photographs. the orthognathic surgery included a counterclockwise rota- was constricted, with anterior and posterior crossbites, the tion of the mandibular occlusal plane with advancement of mandibular arch showed slight anterior crowding, and there pogonion, segmentation of the maxilla with advancement was a 5 mm of negative overjet and an overbite of 3 mm. and expansion, and surgical protrusion of the chin. The pros Maxillary and mandibular midlines were coincident with the and cons of these procedures are discussed. facial midline. The mandibular third molars and the maxil- lary right second premolar were impacted (Figures 1, 2, 3,and 2. Case Presentation 11 and Table 1). A 17-year-and-9-month-old female, who had menarche at 12, 3. Treatment Objectives came for orthodontic treatment to the private orthodontic office with the chief complaints of poor facial esthetics asso- The primary treatment objectives were to correct the Class ciated with mandibular and chin protrusion. Clinically, the III canine relationship, overjet, and overbite and especially patient did not present an acceptable facial balance; the soft to improve facial esthetics. The complementary treatment tissue profile was concave, with strained lip closure. Intraoral objectives were to establish good functional and stable and dental cast examinations demonstrated severe Class III occlusion and to improve the smile characteristics and dental and canine relationships, (molar 3/4-cusp Class III on esthetics. the right side and full-cusp Class III on the left side). Spaceanalysiswasperformedatthestartofthetreatment 4. Treatment Alternatives to assess the space; however, no discrepancy was found. Crowding analysis was also performed and a negative dis- One of the treatment options consisted of extraction of the crepancy model of 1 mm was found. The maxillary arch impacted maxillary right second premolar and the mandibular Case Reports in Dentistry 3

Figure 2: Pretreatment dental casts.

improving her facial esthetics and the maxilla appeared to be retruded, the third option was chosen because it would be performed in only one surgical intervention.

5. Treatment Progress Preoperative orthodontic preparation was conducted with Figure 3: Pretreatment panoramic radiograph. preadjusted 0.022 × 0.030-inch fixed appliances. After extrac- tion of the right second maxillary premolar and the mandibu- lar third molars, leveling and alignment with Nitinol and stainless steel archwires of progressively increasing thickness third molars, followed by surgically assisted rapid maxillary were performed. After leveling and alignment, 0.021 × 0.025- expansion to improve the constricted maxillary arch and inch stainless steel rectangular archwires were placed in the extraction of the mandibular first premolars. The use of mini- maxillary and mandibular arches in preparation for surgery. implants as mandibular would help in reducing the Kobayashi hooks were then attached to all brackets in both overjet and correct the slight mandibular anterior crowding, arches to allow placement of 1/4-inch intermaxillary resulting in Classes I and III molar relationships on the right after surgery (Figure 4). The presurgical orthodontic phase and left sides, respectively, and Class I canine relationships. lasted 11 months. The other treatment alternative would be extraction of The surgical procedures included a Le Fort I osteotomy the impacted right second maxillary premolar and the mand- for expansion, advancement, impaction, and rotation of the ibular third molars, followed by surgically assisted rapid maxilla to correct the occlusal plane inclination. There was maxillary expansion to improve the constricted maxillary 2 mm of impaction of the anterior portion of the maxilla arch and mandibular setback. and 5 mm of extrusion in the posterior region. A bilateral The third option included extraction of the impacted sagittal split osteotomy was performed in order to allow coun- right second maxillary premolar and the mandibular third terclockwise rotation, accompanying the maxillary occlusal molars followed by surgically assisted segmented maxillary plane. Horizontal osteotomy of the mandibular symphysis expansion associated with advancement and impaction and was performed. This genioplasty was performed due to the counterclockwise rotation of the mandible with pogonion impactthatotherfacialosteotomiesplannedcausedonthe advancement and surgical chin protrusion. prominence of the chin. Rigid internal fixation with titanium The treatment options were presented to the patient and plates and screws of 2 mm system was used without any discussed. Because the patient was very concerned with intermaxillary fixationFigure ( 5). 4 Case Reports in Dentistry

Figure 4: Presurgical intraoral photographs.

Table 1: Pretreatment and posttreatment cephalometric status measurement. 7-years Variables Pretreatment Posttreatment posttreatment Maxillary component ∘ SNA ( ) 88.7 89.6 89.9 A-N Perp (mm) 7.5 8.3 8.5 Figure 5: Postsurgical panoramic radiograph. Mandibular component ∘ SNB ( ) 87.9 88.3 90.0 P-N Perp (mm) 12.9 14.4 16.1 P-NB −0.4 1.0 2.3 During the postoperative period, sensory and objective Maxillomandibular relationship ∘ − tests were performed to monitor the expected losses of sen- ANB ( ) 0.8 1.3 0.1 ∘ sitivity.Bianchini,1995,statesthatthesensationimpairment NAP ( ) 2.1 1.6 1.0 in an orthognathic surgery can occur partially (paresthesia or Facial growth pattern ∘ hypoesthesia) or completely (), caused by micro- SNGoGn ( ) 34.7 30.5 29.9 damage or nerve compressions. These mentioned alterations SN.Gn 64.7 62.6 61.5 can recover spontaneously; however, if a complete lesion Maxillary dentoalveolar component occurs in the alveolar inferior nerve, a definitive anesthesia is ∘ determined. This sensitivity deficit may occur in the mental 1.NA ( ) 23.8 27.3 28.8 region, mandibular dentoalveolar region, and lower lip, when 1-NA (mm) 4.8 4.9 6.1 mandibular osteotomies are executed [11]. Sensory tests were Mandibular dentoalveolar component ∘ performed using synthetic brushes of various calibers, 1.NB ( )29.622.924.0 whereas thermal tests were assessed using needles of various 1-NB (mm) 7.7 3.9 5.0 gauges in the lower lip region bilaterally. Return of normal ∘ IMPA ( ) 86.9 84.0 86.2 sensations was observed in the fourth month after the surgery. Considering the patient’s reports of improvement in Dental relationships INTERINCISAL sensations, no special treatment was necessary. After seven ∘ 125.8 128.0 126.7 years, the neurosensitivity was normal, mouth opening was ( ) 40 mm, and mandibular functions were totally normal. Soft tissue component UPPER LIP to S After orthognathic surgery, orthodontic finishing was −1.6 −1.8 0.0 performed in order to obtain better teeth interdigitation. (mm) LOWER LIP to The patient was instructed to wear vertical intermaxillary 3.6 −0.8 −0.1 elasticsfor20hoursadayduring45daysandthengradually S (mm) reduce the wear time. Occlusal equilibration was performed after appliance removal to refine the interocclusal contacts. A maxillary Hawley and a fixed canine to canine mandibular retainer were placed. Total treatment time was The maxillary incisors were labially tipped and slightly 20 months (Figure 8). protruded, the mandibular incisors were lingually tipped The facial posttreatment photographs show improvement and retruded, and there was reduction in facial convexity in the facial profile. The patient was satisfied with his teeth, (Table 1). Root resorption was minimal (Figure 10). Transver- profile, and smile line. The final occlusion shows ClassI sal increases of 4 mm were observed in the intercanine region canine relationship on both sides and normal overjet and (49 mm to 53 mm) and in the intermolar region (63 mm to overbite (Figures 6, 7,and11). 68 mm). Superimposition of the cephalometric tracings Case Reports in Dentistry 5

Figure 6: Posttreatment extraoral and intraoral photographs. shows the maxillary advancement and the mandibular correct transverse deficiencies. While surgically assisted rapid counterclockwise rotation, projecting the chin anteriorly maxillary expansion (SARME) is performed as the first step (Figure 11). of a 2-step approach, segmental Le Fort I is performed The case remained stable 7 years after treatment (Figures concomitantly with the osteotomy. Because time is required 10 and 11 and Table 1); the maxillary and mandibular incisors for expansion and a postoperative healing period is necessary had a slight increasing in their positive buccolingual inclina- after SARME, the entire surgical orthodontic treatment time tion. The soft profile and the pogonion had mild advancement can be prolonged [12]. During treatment planning, some 7 years after treatment, probably due to a late growth of the factors to decide between SARME and segmental Le Fort I patient’s mandible. We can see only a small diastema between should be considered: presence of other maxillary problems, the maxillary central incisors that did not bother the patient, magnitude of width deficiency, and stability. so no action was taken (Figure 9). Regarding stability, it is known that maxillary expansion is the most unstable movement in orthognathic surgery after the first postoperative year [13]. Comparisons between tech- 6. Discussion niques of rapid maxillary expansion surgically assisted (two surgical times) and segmented maxillary osteotomy (one Correction of maxillary constriction is an important part surgical time) found that there are no long-term differences. of the surgical-orthodontic treatment plan. Segmental Le Studies show slightly higher stability when the surgery is Fort I osteotomy is considered an effective procedure to performed in a single procedure [12, 14]. 6 Case Reports in Dentistry

Figure 7: Posttreatment dental casts.

increased vertical dimension, and if it was not performed the patient would have an even more vertical profile. With the surgical repositioning of the mandible for the correction of a prognathic mandible, the technique for the surgical correction of dentofacial deformities has developed into a well-defined science and a fascinating art form. Bilateral sagittal ramus osteotomy is currently the most popular surgical procedure for the correction of dentofacial Figure 8: Posttreatment panoramic radiograph. deformities involving the mandible [19]. Bilateral sagittal split osteotomy was performed to provide counterclockwise rota- tion of the mandible and chin advancement to enhance den- tal, skeletal, and soft tissue relationships. The advancement of It was necessary to perform a maxillary Le Fort I oste- the chin can be used to improve almost any skeletal abnor- otomy, with maxillary segmentation to allow expansion, mality. The technique is primarily used only for esthetic rea- advancement, and impaction of the maxilla, due to maxillary sons. Moreover, its use is independent of patient care with the constriction and posterior and anterior crossbites. However, appearance of this area of the face. Often, the surgeon has to this procedure should be avoided when a great amount of draw the patient’s attention to the need for genioplasty when maxillary expansion is needed, because the palatal tissue other facial osteotomies are planned because of the impact thickness does not allow large immediate expansion [15]. that these osteotomies have on the prominence of the chin Surgery was performed in only one surgical intervention, [1]. because it decreases the overall treatment time and the Due to the impact of the planned facial osteotomies, the expansion movement is better controlled due to the rigid mandible was rotated counterclockwise, and it was necessary internal fixation, which increases stability of the surgical to move the chin forward to correct facial height and improve results [16–18]. the esthetics of face. The maxilla was impacted 2 mm in the anterior region to According to the literature, maxillary advancement is the correct the great exposure of the incisors, because maxillary second surgical procedure more associated with relapses in advancement and the surgical access (healing retraction) maxillofacialsurgery,sothatthepossibilityofrelapsesof2to increase exposure of the maxillary incisors, by changes in 4 mm which occurs is 20% or less. An acceptable stability in upper lip posture. There was also 5 mm of extrusion in the combined maxillary and mandibular surgical procedures is posterior region of the maxilla. However, this subtle obtained when rigid internal fixation is used. Three surgical impaction was performed because the patient has an procedures are susceptible to relapses of 2 to 4 mm in 40 to Case Reports in Dentistry 7

Figure 9: Posttreatment extraoral and intraoral photographs after 7 years.

++ + + ++ +++

+ Figure 10: 7-year posttreatment panoramic radiograph. ++

50% of the cases: the setback of the mandible, the inferior maxillary repositioning, and the maxillary expansion. The movement direction of the surgical procedures, the type of fixation, and the surgical technique can affect the stability Figure 11: Pretreatment, postsurgical, and 7-year posttreatment of orthognathic surgery [20]. Stability has improved with cephalometric superimposition (S-N). the use of stable internal fixation, once it accelerates bone repair, allows immediate mandibular functions, avoids com- plications from maxillomandibular lock, and facilitates and feeding [21]. themhadatleast2mmofincisorsormolarsintrusion.It Another study evaluated the stability of maxilla superior was observed that skeletal or tooth movement of 2 mm or repositioning using Le Fort I osteotomy in various time more occurred in approximately 20% of the patients. During intervals. A total of 61 patients were assessed and all of thefirst6weeksaftersurgery,maxillashowedastrong 8 Case Reports in Dentistry tendency to move up in nonstable patients. Posterior and mandibular setback, the counterclockwise rotation resulted anterior maxillary regions tended to be vertically stable in in an unusual advancement of pogonion, projecting the chin 90%and80%ofpatients,respectively.Horizontally,the anteriorly, accompanying the maxillary occlusal plane. This maxilla was stable in 80% of cases. The changes occurred were protocol showed good occlusal and esthetic results, showing related to a move back of the maxillary anterior region when stability 7 years posttreatment. the jaw was surgically advanced. After the first six weeks, the maxillary posterior region was vertically stable in all patients; Conflict of Interests however, in 20% of them, the cephalometric points of maxil- lary anterior region moved downward, in opposite direction The authors declare that there is no conflict of interests of the movement which occurred during the surgical proce- regarding the publication of this paper. dure. No evidence was found that the amount of presurgical orthodontic movement of incisors, the multiple segmentation ofthemaxillainsurgery,thepresenceorabsenceofmen- References toplasty and suspension wires, and the number of surgical [1] M. Miloro, Peterson's Principles of Oral and Maxillofacial procedures constitute risk factors for stability. No statisti- Surgery, vol. 2, People’s Medical Publishing House, Shelton, cally significant correlation was found between direction of Conn, USA, 2nd edition, 2011. surgical movement and direction of postsurgical movement [2] E. C. Guyer, E. E. 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